Health Insurance Chapter 5:Legal And Regulatory Insurance

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  • 1/10 Questions

    A patients spouse comes to the office and request diagnostic and treatment information about his wife. The spouse is the primary policy holder  on which his wife is named on the policy as a dependent. The insurance specialist should

    • Allow the patients spouse to review the actual record in the office but not release a copy
    • Inform the patients spouse that he must request the information from the insurance company
    • Obtain a signed patient authorization from the wife before releasing patient information
    • Release a copy of the information to the patients spouse because he is the primary policy holder
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About This Quiz

This quiz in Health Insurance Chapter 5 focuses on legal and regulatory aspects, testing knowledge on patient authorization, information privacy, and distinguishing between Medicare fraud and abuse. It's crucial for professionals in legal, healthcare, and insurance fields.

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  • 2. 

    An attorney calls a physicians office and requests that a copy of his clients medical record be immediately faxed to the attorneys office. The insurance specialist should?

    • Call the HIPPA hot line number to report a breach of confidentiality

    • Explain to the attorney that the office does not fax or copy patients records

    • Instruct the attorney to obtain the patients signed authorization

    • Retrieve the patients medical record and fax it to the attorney

    Correct Answer
    A. Instruct the attorney to obtain the patients signed authorization
    Explanation
    The insurance specialist should instruct the attorney to obtain the patient's signed authorization because sharing a patient's medical record without their consent is a violation of HIPAA regulations. The specialist should prioritize patient confidentiality and ensure that proper procedures are followed before releasing any medical information.

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  • 3. 

    The physician submitted a claim on which he had accepted assignment-of-benifits statement for the office. The payer determined that reasonable charge for services provided to the patient was $500 and reimbursed the physician $400. The patient paid $200 at the time services were provided. (The payer required the patient to pay a 20% coinsurance amount when services were provided.) The insurance specialist should

    • Charge the patient an additional $100

    • Refund the patient a $100 overpayment

    • Return the $400 check to the payer

    • Submit the patients name to collections

    Correct Answer
    A. Refund the patient a $100 overpayment
    Explanation
    The physician submitted a claim for $500, but the payer determined that the reasonable charge for the services provided was only $400. The payer reimbursed the physician $400 and the patient paid $200 at the time of service, which was the required 20% coinsurance. This means that the patient overpaid by $100 ($200 - $100). Therefore, the insurance specialist should refund the patient the $100 overpayment.

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  • 4. 

    Which is considered Medicare fraud?

    • Billing for services that were not furnished and misrepresenting diagnosis to justify payment

    • Charging excessive fees for services, equipment, or supplies provided by the physician

    • Submitting claims for services that are not medically necessary to treat a patients condition

    • Violating participating provider agreements with the insurance companies and government programs

    Correct Answer
    A. Billing for services that were not furnished and misrepresenting diagnosis to justify payment
    Explanation
    Medicare fraud refers to intentionally billing for services that were not actually provided and misrepresenting the diagnosis to justify receiving payment. This involves deceitfully claiming reimbursement for services that were not rendered, which is a fraudulent practice. This type of fraud can result in financial losses for the Medicare program and can also harm patients by subjecting them to unnecessary medical procedures or treatments.

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  • 5. 

    A commercial insurance company sends a letter to the physician requesting a copy of a patients entire medical record in order to process a payment. No other documents accompany the letter. The insurance specialist should? 

    • Contact the patient via telephone to alert him about the request

    • Let the patients physician handle the situation personally

    • Make a copy of the record and mail it to the insurance company

    • Require a signed patient authorization letter from the insurance company

    Correct Answer
    A. Require a signed patient authorization letter from the insurance company
    Explanation
    The correct answer is to require a signed patient authorization letter from the insurance company. This is because the insurance company is requesting a copy of the patient's medical record, which contains sensitive and confidential information. Requiring a signed authorization letter ensures that the patient has given their consent for the release of their medical records to the insurance company. This helps to protect the patient's privacy and comply with legal and ethical requirements. Contacting the patient or letting the physician handle the situation personally may not be necessary or appropriate in this case.

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  • 6. 

    A patient receives services on April 5, totaling $1,000. He paid a $90 coinsurance at the time services were rendered. (The payer required the patient to pay a 20% coinsurance at the time services were provided) The physician accepted assignment, and the insurance company established the reasonable charge as $450. On July 1 the provider received $360 from the insurance company. On August 1 the patient received a check from the insurance company in the amount of $450. The overpayment was__________, and the_____________must reimburse the insurance company. 

    • $450, patient

    • $450, physician

    • $550, patient

    • $640, physician

    Correct Answer
    A. $450, patient
    Explanation
    The patient received a check from the insurance company in the amount of $450, which is the same as the reasonable charge established by the insurance company. Therefore, there was an overpayment of $450 made to the patient. The patient must reimburse the insurance company for this overpayment.

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  • 7. 

    Which is considered Medicare abuse?

    • Falsifying certificates of medical necessity, pans of treatment, and medical records to justify payments

    • Improper billing practices that result in Medicare payment when the claim is legal responsibility of another third-party payer

    • Soliciting, offering, or receiving a kickback for procedures and/or services provided to patients in the physicians office

    • Unbundling codes;that is, reporting multiple CPT codes on a claim to increase reimbursement from a payer

    Correct Answer
    A. Improper billing practices that result in Medicare payment when the claim is legal responsibility of another third-party payer
    Explanation
    Medicare abuse refers to any practices that result in unnecessary costs to the Medicare program. Improper billing practices that result in Medicare payment when the claim is the legal responsibility of another third-party payer can lead to unnecessary payments from Medicare. This is considered Medicare abuse because it involves billing Medicare for services that should be covered by another payer, resulting in unnecessary costs for the Medicare program.

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  • 8. 

    The patient underwent office surgery on October 10, and the third-party payer determined the reasonable charge to be $1,000. The patient paid 20% coinsurance at the time of the office surgery, The physician and patient each received a check for $500, and the patient signed the check over to the physician. The overpayment was__________, and the_________must reimburse the insurance company  

    • $200, patient

    • $200, physician

    • $500, patient

    • $500, Physician

    Correct Answer
    A. $200, physician
    Explanation
    The overpayment was $200, and the physician must reimburse the insurance company. This is because the patient paid 20% coinsurance at the time of the office surgery, which amounted to $200. However, both the physician and the patient received a check for $500 each. Since the patient signed the check over to the physician, the physician received an additional $200 that was not owed to them. Therefore, the physician must reimburse the insurance company the overpayment of $200.

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  • 9. 

    An insurance company calls the office to request information about a claim. The insurance specialist confirms the patients dates of service and the patients negative HIV status. The insurance specialist 

    • Appropriately released the dates of service but not the patients negative HIV status

    • Breached patient confidentiality by confirming the dates of service

    • Did not breach patient confidentiality because the patients HIV status was negative

    • Was in compliance with HIPPA provisions concerning release of dates of service and HIV status

    Correct Answer
    A. Appropriately released the dates of service but not the patients negative HIV status
    Explanation
    The insurance specialist appropriately released the dates of service but not the patient's negative HIV status because sharing the dates of service is necessary for the insurance company to process the claim. However, disclosing the patient's HIV status would be a breach of patient confidentiality as it is sensitive medical information that should not be shared without the patient's consent. This action is in compliance with HIPAA provisions, which protect patient privacy and require healthcare providers to safeguard sensitive health information.

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  • 10. 

    The 66 year old patient was treated in the emergency department (ED) for a fractured arm. The patient said, "I was moving a file cabinet for my boss when it tipped over and fell on my arm" The facility billed Medicare and received reimbursement of $550. The facility later determined that Medicare was not the payer because this was a workers compensation case. 

    • Is guilty of both fraud and abuse according to HIPPA because of accepting the $550

    • Must give the $550 check to the patient, who should contact workers compensation

    • Should have billed the employers workers compensation payer for the ED visit

    • Was appropriately reimbursed $550 by medicare for the emergency department visit.

    Correct Answer
    A. Is guilty of both fraud and abuse according to HIPPA because of accepting the $550

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  • Mar 20, 2023
    Quiz Edited by
    ProProfs Editorial Team
  • Oct 30, 2012
    Quiz Created by
    Phliproc
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